sexual dysfunction in men Flashcards
what is the definition of early ejaculation in men?
- an inability to control ejaculatory time in the majority of situations
- this causes distress
- mean time to ejaculation is < 1 minute prior to penis entering the vagina or < 3 minutes if penile penetration has occurred
Note all the studies have only looked a cis male heterosexual couples…
What is the ‘normal’ time to ejaculation in men?
Normal time is approximately 5 and half minutes (5.4 -6 minutes IVELT - intra-vaginal ejaculatory latency time)
what are some of the causes of PE (Premature ejaculation) and how could you categories them?
we don’t know what the cause is of PE in the majority of cases
it can be acquired or lifelong
Lifelong causes –> patients may have just failed to learn the ability to control ejaculation, it could be inherited or it could be due to 5HT dysfunction
Acquired causes:
- psychological
- relationship issues
- social pressure
- organic causes - chronic pelvic pain in men, benign prostatic hypertrophy, erectile dysfunction, endocrine or neurological causes
You diagnose Ben a 36 year old male with premature ejaculation. He is keen to try some medical treatment - what is the first line option you would consider?
Topical EMLA cream - apply FTU to the frenulum 10-20 minutes before sex, ensure they use a condom otherwise can affect partners ability to orgasm
it is trial error sometimes need some more sometimes less and it is a process of finding what helps for Ben
usually use this in conjunction with psychological support e.g. stop and start technqiues in sex therapy
You review ben 6 months after a diagnosis of PE. He has been having sex therapy and using EMLA cream with little benefit. he has read about sildenafil and would like to try it. What are the contra-indications to PDE 5 inhibitors?
previous MI or stroke within the last 90 days
concurrent use of nitrates, including GTN or nitrate poppers as recreational drugs
uncontrolled cardiac disease/ IHD
note some medications can interact
How do PDE 5 inhibitors work to help maintain an erection
PDE 5 inhibitors work to block the enzyme PDE5 that would break down cGMP levels. This leads to an increase in cGMP levels that works to induce smooth muscle relaxation in the BVs to increase blood flow into the penis.
in PE prior to trying PDE 5 inhibitors what other class of medications might be useful to try and help to delay ejaculation
Anti-depressants specifically SSRIs ( fluoxetine and paroexteine are all off licence for this indication, taken daily)
only SSRI licensed for this indication is dapoxetine
Out of the following list which is the only medication licensed for the treatment of premature ejaculation?
a) Paroxteine
b) sertraline
c) dapoxetine
d) fluoxetine
c - dapoxetine
how do you take dapoexteine for PE?
a) daily
b) prn
c) monthly
b - PRN - take it 1-3 hours before sex, it is a short acting SSRI
it has a risk of orthostatic hypotension and therefore lying and standing BP should be measured before prescribing
list the side effects associated with dapoxetine
nausea
dizziness
headache
risk of orthostatic hypotension (do L&S BP prior to prescribing)
prior to prescribing dapoxetine what investigation do you need to do and why?
lying and standing BP due to risk of orthostatic hypotension
what is the definition of erectile dysfunction?
Erectile dysfunction is the persistent inability to attain or maintain an erection in order to complete/perform a sexual activity. This inability causes the patient distress
how common is ED?
very common approximately 40% of the population suffer with ED
prevalence increases as men get older
what are some of the causes of erectile dysfunction - how could you categorise these causes
psychological
neurological (DM, pelvic surgery, spinal cord trauma, CNS tumours, pelvic radiotherapy, MS)
endocrine (testosterone deficiency, hypogonadism, hyper/hypo thyroidsism, hyperprolactinaemia)
cardiovascular ( hypertension, PVD, DM, IHD, atherosclerosis)
pharmacological (anti-hypertensives - diuretics common, anti depressants - SSRIs, party drugs - coke, heroin, weed etc, anti-epileptics)
what would your approach be to a man who presents in your clinic with symptoms of ED?
history - ask what they mean, is it lifelong or acquired, global or situational, pmhx, and drug hx very important, talk about their relationship etc
examination - genital examination, consider prostate exam if relevant, may need neuro exam, BP, BMI,
investigations - everyone should have CVD check - glucose/hba1c, lipids, total testosterone, consider TFTS, prolactin, FSH/LH and PSA if relevant to the history
calculate Q risk 3
what are the general measures that all men should be advised can help in the treatment of ED?
lifestyle changes - lose weight, smoking cessation, cut back on alcohol intake, exercise etc
what is the first line pharmacological treatment of ED?
PDE 5 inhibitors e.g. sildenafil) = viagra
taken on demand - 1-3 hours before sex, advise the patient they have 8 hours to have sex, not to clock watch!!
some PDE5 inhibitors are longer acting and work better for some patients
If PDE5 inhibitors have failed to work for the treatment of ED what would the next pharmacological treatment be that you would suggest?
Intracarvenosal alprostadil or intraurethral injections of alprostadil
what is alprostadil and how does it work?
does it have to be injected into the muscle or urethra or are there any other ways to give the medications
alprostadil is a vasodilator (is a prostaglandin analogue) and works to increase blood flow into the penis by causing smooth muscle relaxation
it can also be given topically in a cream
If a patient declines pharmacological treatment for ED what could you try first line?
Vacuum pumps
what is the final management option if topical, injections and oral treatment for ED have failed?
penile prosthesis
A patient with ED total testosterone level comes back at 6. How should he be managed?
total testosterone is low. Therefore needs testosterone replacement this can be through oral medication or injections. trial of treatment for 6/12
normal testosterone is 12 and above.
NATSAL 3 demonstrated what proportion of women report sexual difficulties?
a) 10%
b) 22%
c) 51%
d) 75%
c - 51% of women reported issues with sex however only 11% of these women reported that this causes them distress
what is the most common sexual difficulty reported by women in the NATSAL 3 survey?
a) anorgasmia
b) pain with sex
c) lack of enjoyment
d) lack of interest in sex
d- lack of interest in sex (35%)
what is responsive desire?
Responsive desire describes a situation in which you become sexually aroused. You didn’t desire to have sex but you respond to a sexual stimulus e..g you are washing the dishes and your partner starts to kiss your neck.. you then become aroused and go on to have sex. This is normal = responsive desire.
However a lot of patients attend thinking they lack spontaneous desire.
what is the DSM 5 definition of lack of sexual interest/ arousal disorder
feelings of sexual interests or desire and responsive desire are absent or diminished.
Absent or decreased genital and non genital sensations during sex
this causes distress and must have been present for at least 6 months
what are the pharmacological treatments that can be used in women to help treat lack of sexual desire or interest?
- PDE 5 inhibitors - these are off licence, can be good for women who struggle with sexual arousal and low desire on an SSRI or post SSRI treatment
- local oestrogen cream/lubricants –> good for peri and postmenopausal women, struggling with objective arousal
- systemic HRT including tibolone has been shown to enhance sexual desire.
- testosterone gels or implants –> off licence, clinical trials have shown some efficacy in increasing desire and arousal in women (trial for 3-6 months)
what are the non-pharmacological treatments that can be used in women to help treat lack of sexual desire or interest?
mindfullness, sex therapy, relationship/couple therapy
sex toys
address underlying conditions/illness
what is the prevalence of superficial dyspareunia?
a) 12%
b) 25%
c) 40%
d) 60%
a) 12% of women suffer with superficial dyspareunia
what are some of the causes of vulval pain related to a specific cause?
- infection: thrush, STI, PID
- dermatoses - LS, VIN, paget’s disease
- congenital - stricture of the hymen or vagina
- surgical - post episiotomy, FGM
- neurological - pudendal neuralgia, spinal nerve compression
when vulva pain is not deemed to be secondary to specific condition what is the diagnosis given?
Vulvodynia
how do patients that present with vulvodynia describe the pain?
The pain is described as a burning sensation can be generalised or localised and it can be provoked or unprovoked.
what contraception can be linked to vulvodynia?
Oral contraceptive pill
You examine Alice a 32 year old female who has presented to your clinic with symptoms of superficial dyspareunia. On examination of the vulva she experiences pain on palpation of the entrance of the vagina in response to cotton wool stimulus. What is the medical name given to the condition in which women experience pain in response to a non painful stimulus?
Allodynia
how should vulvodynia be managed?
MDT approach (physios, medics, psychologists)
what are the medical treatment options that can be used to help treat vulvodynia?
- local anaesthetics - 5% lidocaine ointment
- TCA (tricyclic anti-depressants) e.g. amitryptiline 10mg OD (up to 60mg normally)
others include - gabapentin and pregabalin
these medical Rx should be used alongside non pharmacological treatments including mindfulness, specialist women’s health physiotherapists
how common is vaginismus?
affects about 12% of women so it is common!
what is vaginismus?
an involuntary contraction of the musculature of the outer third of the vagina interfering with intercourse, causing distress and interpersonal difficulties.
it is more of a clinical syndrome
How does vaginismus cause difficulties when having sex?
Vaginismus leads to the involuntary contraction of the pelvic floor muscles which leads to an inability for penile penetration and in some cases even digital penetration. This causes pain and then fear and viscous cycle.
what causes vaginismus?
we don’t know! in a large proportion of cases patients may have had previous bad experiences including sexual abuse
What is the management approach to vaginismus?
- stop the pain cycle –> pscyhological help
- pelvic floor assessment & physiotherapy to try and help get the pelvic floor to relax
- self exploration with fingers/ vaginal trainers (previously called dilators) to try and desensitise the pain and fear
out of the following PDE5 inhibitors which has the longest half life
a) sildenafil
b) tadalafil
c)Vardenafil
d) Avanafil
b) tadalafil (half life up to 17.5 hours)
can be taken daily or PRN
note PRN is off licence use
out of the following list which PDE5 inhibitor is not affected by consumption of food at same time as taking it?
a) sildenafil
b) tadalafil
c)Vardenafil
d) Avanafil
b) tadalafil
what is the half life of sildenafil
3-5 hours
what percentage of men won’t respond to PDE5 inhibitors (if no diabetes)
a) 10%
b) 20%
c) 40%
d) 50%
b) 20%
what percentage of men won’t respond to PDE5 inhibitors if co-existent diabetes
a) 10%
b) 20%
c) 40%
d) 50%
c) 40%
can you name two questionnaires out of the following list that can be used to assess the severity of ED?
a) Qrisk 3
b) DSRP
c) erectile dysfunction questionnaire BSSM
d) International index of erectile dysfunction
e) UK index of erectile dysfunction
f) sexual health inventory for men
d) international index of erectile dysfunction
f) sexual health inventory for men
a patient presents requesting sildenafil for ED. You check his medications, out of the following list which are CI medications to prescribe PDE5 inhibitors:-
a) metformin
b) bisoprolol
c) nicorandil
d) GTN
e) aspirin
f) ISMN
g) ramipril
h) codeine
c) nicorandil
d) GTN
f) ISMN
all nitrates and don’t forget recreational drugs = poppers!
before starting testosterone therapy in someone with low testosterone (male) in ED what other blood test should be done and why?
PSA as testosterone can make prostate cancer grow
what exercise if performed for more than 3 hours a week can cause ED in men?
cycling
if prescribing a PDE5 inhibitor after how many weeks should you follow them up
6-8 weeks to assess response
what are the routine investigations needed to investigate for causes of ED
- CVD assessment - BP, HR, BMI, waist circumference
bloods: lipids, HbA1c or fasting BG
(calculate Qrsik3 = 10 year risk of CVD)
early morning total testosterone 9am-11am, fasted sample ( if low then repeat + do FSH, LH, SHBG, prolactin)
Not routine:-
only do PSA if LUTS symptoms, or due to LUTS you have done a prostate exam and feel it is required (also need to do PSA prior to starting testosterone therapy)
only do TFTs if symptoms suggestive, LFTs/U&Es if symptoms or concerns - not routine
David is a 56 year old man. He comes to the GP stating he hasn’t been able to ejaculate for the past 6 months. He is able to get an erection and gets the sensation of orgasim but no ejaculate. He had a TURP for BPH 9 months ago. What do you think is the diagnosis:
a) absent ejacualtion
b premature ejaculation
c) retrograde ejaculation
d) erectile dysfunction
c) retrograde ejaculation
what conditions/ surgical Rx
pharmacological causes
medical problems that can cause retrograde ejaculation
BPH
DM -autonomic neuropathy
MS
Surgical:
TURP
prostectomy
retroperitoneal lymph node resection
bladder neck surgery
drugs e.g. alpha adrenergic blockers
how can you confirm retrograde ejaculation
centrifuge urine 10mins post presumed ejaculation
how can retrograde ejaculation be treated
a) EMLA cream
b) dapoxeteine
c) alpha-agonist (e.g. pseudoephedrine)
d) PDE5 inhibitors e.g. sildenafil
c) alpha agonist e.g. pseudoephedrine, epidrine or midodrine (these are second line after TCA - imipramine
how might a cis-male patient present with retrograde ejaculation
‘dry’ ejaculation or low volume of ejaculation
post void urine after orgasm might be very cloudy
what is the pathophysiology of retrograde ejaculation
usually during ejaculation urethral pressure > bladder pressure and the sphincter to the bladder closes, however for some reason this doesn’t happen and seminal fluid travels back into the bladder
often secondary to recent surgery e.g TURP, bladder surgery or retroperitoneal lymph node resection/retrieval
what is first line Rx option for retrograde ejaculation
a) sildenafil
b) doxasocin
c) tamsulosin
d) imipramine
e) dapoxeteine
d) imipramine (TCA) first line
second line is alpha adrenergic receptors (all end e.g pseudoephrine)
what class of medications can cause retrograde ejaculation
alpha adrenergic blockers e.g. tamsulosin, suffix “-osin.” These medications include alfuzosin, doxazosin, terazosin, tamsulosin, and prazosin
all used to Rx BPH. aim to reduce bladder tone. whereas in retrograde ejacualation we want to increase it.
what is Odynorgasmia or dysorgasmia
painful ejaculation
what conditions are associated with painful ejaculation
CPPS (chronic pelvic pain syndrome)
prostatitis
bph
management involves addressing the cause
Ashley is 52 years old. He presents to his GP with painful erections and says he thinks he can feel a lump in the midshaft of the penis. He has noticed when he gets an erection the penis looks curved and it is extremely painful.
What do you think is the DD?
a) Retrograde ejaculation
b) CPPS
c) Peyronie’s disease
d) Prostatitis
e) Erectile dysfunction
c) Peyronie’s disease
what causes Peyronie’s disease
we don’t really know
thought due to development of scar tissue that develops into plaques underneath penile tissue, causing a curvature of the penis with an erection. Very painful erections.
how can we Rx Payronie’s disease
High dose Vit E and Potaba (potassium aminobenzoate) frequently tried with minimal response.
Surgical intervention (Nesbit’s procedure) to straighten the penis.
Patients with significant deformity and ED may require a penile prosthesis to be inserted.
what is retarded ejaculation
absent or difficulty to ejaculate (note not retrograde ejaculation)
what are the common causes of retarded/absent ejaculation
often thought to be psychological but need to rule out:
- neurological (DM, MS, SC injury)
-hypogonadism - hypothyroidism
can also be caused by medication:
SSRI, alpha blockers (doxasocin, tamsulosin)
management of retarded/absent ejaculation
often difficult to Rx -
- psychological support
- no licenced medication, nothing found of benefit in terms of medical Rx
- if spinal cord injury - low grade shock wave therapy
match the definition
is sexual desire or attraction to an inanimate object or a part of the
body that is not typically viewed as sexual.
a) paraphilia
b) fetish
c) paraphilic disorder
b) fetish
“any intense and persistent sexual interest other than sexual
interest in genital stimulation or preparatory fondling with inanimate objects, situations, children, non consenting adults or animals”
a) paraphilia
b) fetish
c) paraphilic disorder
a) paraphilia
“is currently causing distress or
impairment to the individual or a paraphilia whose satisfaction has entailed
personal harm, or risk of harm, to others.”
a) paraphilia
b) fetish
c) paraphilic disorder
c) paraphilic disorder
who are paraphilia’s more common in?
men or women
men and often a/s/ strong links with personality disorders
becoming sexually aroused by watching an unsuspecting person who is disrobing, naked, or engaged in sexual activity. This causes distress (to be a disorder)
a) Voyeuristic disorder
b) Exhibitionistic disorder
c) Frotteuristic disorder
d) Sexual masochism disorder
e) Sexual sadism disorder
f) Pedophilic disorder
g) Fetishistic disorder
h) Transvestic disorder
a) voyeuristic disorder
involves exposing the genitals to become sexually excited or having a strong desire to be observed by other people during sexual activity. This causes distress and unable to control these urges.
a) Voyeuristic disorder
b) Exhibitionistic disorder
c) Frotteuristic disorder
d) Sexual masochism disorder
e) Sexual sadism disorder
f) Pedophilic disorder
g) Fetishistic disorder
h) Transvestic disorder
exhibitionistic disorder
intense sexual arousal from touching or rubbing against a non-consenting person.
a) Voyeuristic disorder
b) Exhibitionistic disorder
c) Frotteuristic disorder
d) Sexual masochism disorder
e) Sexual sadism disorder
f) Pedophilic disorder
g) Fetishistic disorder
h) Transvestic disorder
c) frotteuristic disorder
involves acts in which a person experiences sexual excitement from being humiliated, beaten, bound, or otherwise abused
a) Voyeuristic disorder
b) Exhibitionistic disorder
c) Frotteuristic disorder
d) Sexual masochism disorder
e) Sexual sadism disorder
f) Pedophilic disorder
g) Fetishistic disorder
h) Transvestic disorder
Sexual masochism disorder
involves acts in which a person experiences sexual excitement from inflicting physical or psychological suffering on another person. Can result in death.
a) Voyeuristic disorder
b) Exhibitionistic disorder
c) Frotteuristic disorder
d) Sexual masochism disorder
e) Sexual sadism disorder
f) Pedophilic disorder
g) Fetishistic disorder
h) Transvestic disorder
e) Sexual sadism disorder
is characterized by recurring, intense sexually arousing fantasies, urges, or behavior involving children under age of 13.
a) Voyeuristic disorder
b) Exhibitionistic disorder
c) Frotteuristic disorder
d) Sexual masochism disorder
e) Sexual sadism disorder
f) Pedophilic disorder
g) Fetishistic disorder
h) Transvestic disorder
f) Pedophilic disorder
is use of an inanimate object as the preferred way to produce sexual arousal. disorder occurs when recurrent, intense sexual arousal from using an inanimate object or focusing on a nongenital body part (such as a foot) causes significant distress, substantially interferes with daily functioning, or harms or may harm another person.
a) Voyeuristic disorder
b) Exhibitionistic disorder
c) Frotteuristic disorder
d) Sexual masochism disorder
e) Sexual sadism disorder
f) Pedophilic disorder
g) Fetishistic disorder
h) Transvestic disorder
g) Fetishistic disorder
involves recurrent, intense sexual arousal from cross-dressing. Disorder is transvestism that causes significant distress or substantially interferes with daily functioning.
a) Voyeuristic disorder
b) Exhibitionistic disorder
c) Frotteuristic disorder
d) Sexual masochism disorder
e) Sexual sadism disorder
f) Pedophilic disorder
g) Fetishistic disorder
h) Transvestic disorder
h) Transvestic disorder
